CARE HOMES FOR OLDER PEOPLE
Cloyda 227 Malden Road New Malden Surrey KT3 6AG Lead Inspector
Alison Ford Key Unannounced Inspection 10th May 2007 10:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Cloyda Address 227 Malden Road New Malden Surrey KT3 6AG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8949 1839 020 8949 1839 cloyda@hotmail.com Mr Vallabhbhai Morarbhai Patel Mrs Dahiben Vallabhbhai Patel Post Vacant Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (25) of places Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: Cloyda is a residential care home registered with the Commission for Social Care Inspection to provide care for up to thirty five people over the age of sixty five, ten of which may have a diagnosis of dementia. The home is a large detached property, located on a main road close to the centre of New Malden. There is easy access to the A3 and to public transport. Accommodation is provided on the ground and first floor which can be accessed by passenger lift. There is a large garden to the rear of the property. Copies of the home’s Statement of Purpose and Service User Guide can be obtained from the Registered Providers on request, as can a copy of the Commission for Social Care Inspection’s most recent inspection report. The latter can also be obtained from The Commission for Social Care Inspection via the internet. Fees at the time of writing range between £442 and £615 and would be discussed prior to admission. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008.At this visit, all of those standards, considered by The Commission for Social Care Inspection, to be key to the inspection process were assessed. When writing this report consideration has also been given to other information received about the service including notification of incidents, pre-inspection comment cards, complaints and concerns. Since the last key inspection, concerns about the home have lead to there being seven additional random visits and there is currently a restriction on the placement of residents into the home by three local authorities. This situation is being monitored very closely and reviewed on a regular basis. Prior to the inspection pre-inspection comment cards, routinely sent to services, had been received from three people who live in the home and two relatives. All of these reflected positive outcomes for residents and satisfaction with the service and the care that is provided although some concerns were raised about the amount of activities offered to residents and whether these provided enough interest and stimulation in their lives. What the service does well:
The people who use this service, who were able to contribute to the inspection process and the relatives who completed comment cards, gave positive feedback about the care that is given in the home. They considered that staff were kind and helpful and that the home was a nice place to live in. Residents appeared happy and content, and seemed to have their personal care needs met. Staff members, appeared caring and were available for residents. Comments were received that “ its nice here” “ everyone is lovely “ I have a nice room “ and “there is nice food to eat here” Assessments of potential residents healthcare needs are undertaken prior to admission to ensure that they can be met in the home and individual care plans identify the help and support that is required. These are reviewed on a regular basis to ensure that changing needs are addressed. Residents say that they enjoy the meals that are served in the home and fresh fruit and drinks are also available for them. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 6 There is low staff turnover in the home , providing continuity of care for those who live there and there are robust recruitment procedures in place to ensure their protection. Visitors to the home are encouraged and a limited amount of structured activities are facilitated. What has improved since the last inspection? What they could do better:
There are still some concerns about the ability of the home to ensure that the needs of those who live there are being met. Although some of the home has been redecorated and new carpets have been laid these are quite ornate and floral in design. These might bewilder resident’s who are confused or who have dementia. Some of the floor slopes down in places and could cause those who are unsteady on their feet to trip. Some bedrooms still need to be redecorated and some beds still need replacing. It was noted that there are still bed bases and headboards that are stained. Some increased signage has been provided, although it would benefit from being bolder in design, and colour co-ordination of various facilities would also be good practice to help orientate residents. Not all bedrooms had call bells that would be in reach of residents when they were in their rooms. Residents must be able to summon assistance when they need it. Designated fire doors leading from the corridor and stairs need to be alarmed so that staff are alerted if a resident opens them and cupboards and sheds need to be locked to prevent any untoward incidents. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 7 Several residents bedrooms are quite sparse and do not contain any of their personal possessions. An effort needs to be made to make these rooms more homely and residents should be encouraged to bring some of their own possessions with them when they move into the home. There is an activities programme in place although, in reality, the opportunity for them to join in anything that would offer any stimulation is limited. One carer is allocated to this role for two hours a day however, they have not received any relevant training. Sing-a-long sessions are advertised but there are only a very small number of CD’s available. Likewise the range of videos is small. On the day of the inspection pop music was being played on the radio, which was not really suitable for those sitting there. Craft sessions appear to centre on colouring in pictures or putting them in scrapbooks. There are books supplied by the local library but few people could read them, although they might enjoy being read to. There is a large garden to the rear of the property but it is all laid to grass, which would be difficult for residents to walk on. Spiritual needs are not addressed at all although there are churches locally that could be approached. This is an area, which needs to be developed to make life more interesting for the residents in the home. There needs to be an increase in suitable activities and opportunities for interaction must be maximised to stimulate residents remaining capabilities. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3,6 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The people who use this service do not have sufficient information available to help them to make a choice as to whether the home will meet their needs and they will be happy living there. EVIDENCE: The Statement of Purpose for the home was seen however; this was written some time ago and now needs to be updated to reflect the current situation within the home. There is also limited information about who can be accommodated and how it is intended that their needs will be met. This must be included in much more detail so that prospective users of the service will know whether the home will be suitable for them, what services they can expect to be provided and whether they would like living there. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 10 There are three copies of the Service User Guide in the home. This too must now be updated to contain all of the information required by The Minimum Standards and provide a useful reference for any residents in the home. It must be written in an easy to understand style, which is suitable for the people for whom it is intended and there must be enough copies for them all to have one each. There was evidence that pre-admission assessments are undertaken to ensure that potential residents needs will be met and Care Managers assessments were also present. It was noted that peoples healthcare needs are considered during this assessment however little information was available about their social preferences. There must be evidence to show that these have also been considered when a decision is made as to whether the home will be suitable for them. The majority of the people who are admitted into the home would be too frail to visit first and see what it is like so it is recommended that a brochure or information pack should be developed for them to look at when the preadmission assessment is undertaken. This home does not offer intermediate care so this standard does not apply. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards7, 8 9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service find that their healthcare needs are generally met and they consider themselves to be well cared for however, they must be given the opportunity to participate in the care planning process so that they are supported in the way that they prefer. They are treated with dignity and respect and medication policies and procedures are in place, which ensure their protection. EVIDENCE: The care plans of four residents currently living in the home were seen. There would seem to have been an improvement in these since the last key inspection and generally, there was good information available about the needs of the residents and the outcomes that were hoping to be achieved. There was less information about exactly how this would be accomplished. The care plans must be seen as a working document which will allow all staff to know exactly
Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 12 how each resident prefers to be supported and must be developed to include this information. There was limited evidence to show that residents or their representatives had been involved in the care planning process even where residents still retained the ability to participate. Staff must ensure that they are involved in the discussions about how they like to be helped wherever possible. It was noted that care plans were written in pencil. Ink or ballpoint pen must be used, preferably black, in order to prevent any unauthorised alterations being made. Care plans are reviewed regularly to ensure that any changes in healthcare needs remain met. There was evidence available to show that other members of the multidisciplinary healthcare team were involved as necessary. Community nurses visit on a regular basis and undertake any nursing tasks that are required. Medication records were in order and at this visit all medication was appropriately stored. Staff were observed treating residents very gently and with kindness and respect. Residents commented that “they are nice girls, they always come and help us” and “they are always lovely and kind”. A comment card that had been received prior to the inspection, which said how “helpful and considerate they were, always doing their best”. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who use this service are offered limited opportunities to participate in activities, which would suit their remaining capabilities and provide them with any stimulation. The food that is served in the home suits their preferences and their visitors would always be welcome. EVIDENCE: There is an activities programme in place although, in reality, the opportunity for them to join in anything that would offer any stimulation is limited. One carer is allocated to this role for two hours a day however, they have not received any relevant training. Sing-a-long sessions are advertised but there are only a very small number of CD’s available. Likewise the range of videos is small. On the day of the inspection pop music was being played on the radio, which was not really suitable for those sitting there. Craft sessions appear to centre on colouring in pictures or putting them in scrapbooks. There are books supplied by the local library but few people could read them, although they might enjoy being read to.
Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 14 There is a large garden to the rear of the property but it is all laid to grass, which would be difficult for residents to walk on. There is little opportunity for any contact with the local community for the people who are living in the home. Although any visitors would always be made welcome there are no organised outings or activities such as shopping trips. Spiritual needs are not addressed at all although there are churches locally that could be approached. The management team consider that there are currently no residents who could be taken out to church. This is an area, which must be developed to make life more interesting for the residents in the home. There must be an increase in suitable activities and opportunities for interaction must be maximised to stimulate residents remaining capabilities. Training for staff must be improved so that they are aware of how to stimulate residents and encourage them to live a fulfilling life despite their limited abilities. The residents that were spoken with confirmed that they enjoyed the meals that were served in the home although they were not observed at this visit. Menus were looked at and they appeared varied and residents are offered a choice although limitations in their cognitive abilities suggest that may not always understand completely. The cook has worked in the home for some time and knows what residents like however; a list of their preferences must be available in the kitchen in the event of any other person having to prepare food. It is recommended that picture menus could be produced to help residents make their choices. Drinks and fruit are available on the table for residents to have at any time. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use this service do not have an appropriate system in place for the effective handling of complaints. Policies and procedures are in place to ensure their protection. EVIDENCE: Information is made available in the Service User Guide about how a complaint, concern or suggestion should be made, and how this will be handled. This information also includes details about how a concern may be raised with the Commission for Social Care Inspection. However, there is no complaints book for any one to use should they so wish. There had been difficulties in the past with keeping a complaints book so alternative methods were discussed during the visit. There must also be a record of any concerns that are raised along with information regarding how they are handled and the eventual outcome. An assurance was given that no complaints had been received about the service since the last inspection. The home has a copy of the Royal Borough of Kingston Council’s vulnerable adult protection procedures. Staff members have undergone training in the
Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 16 Protection of vulnerable adults although it is recommended that this should be updated. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,23,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who use this service are living in an environment, which does not always meet their individual needs or help to ensure their safety. EVIDENCE: A high number of requirements were made at previous inspections of the home regarding poor maintenance of the building, poor hygiene standards and the failure to provide a homely and comfortable atmosphere. Many of these issues have been addressed; some redecoration has been undertaken, lights have been replaced and, some beds have been replaced. Concerns regarding issues around control of infection have also been given consideration. However, there are still serious concerns about the Registered Providers’ ability to meet the specific needs of the residents living in the home.
Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 18 Currently eight of the twenty-two residents living in the home have been diagnosed with dementia and others may have a degree of confusion and memory loss. Although some of the home has been redecorated and new carpets have been laid these are quite ornate and floral in design. These might bewilder residents who have a degree of cognitive impairment. In several places the floor slopes down and could cause those who are unsteady on their feet to trip. Some bedrooms still need to be redecorated and some beds still need replacing. It was noted that there are still bed bases and headboards that are stained. Some increased signage has been provided, although it would benefit from being bolder in design, and colour co-ordination of various facilities would also be good practice. Not all bedrooms had call bells that would be in reach of residents when they were in their rooms. Residents must be able to summon assistance when they need it. Designated fire doors leading from the corridor and stairs must be alarmed so that staff are alerted if a resident opens them and the door that leads out into the laundry must remain locked when not in use. It is recommended that advice should be sought from the Fire Safety officer regarding the most appropriate type of door locks. It was observed that a shed in the garden with tools in and a cupboard with cleaning equipment in it were unlocked and locks must be fitted to these. Several residents bedrooms are quite sparse and do not contain any of their personal possessions. An effort must be made to make these rooms more homely and residents should be encouraged to bring some of their own possessions with them when they move into the home. The home was much cleaner than had been noted on a previous visit and hand washing facilities have improved for staff. The majority of the home was free from malodour. It was noted that some tiles need replacing in the kitchen although they were apparently only broken a few days before the inspection. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service can feel confident that there are sufficient numbers of staff on duty although they would benefit from further training in order to meet their specific healthcare needs. EVIDENCE: Off duty rotas provided evidence that there are sufficient numbers of staff on duty at all times in the home. Due to reduced occupancy in the home no new staff have employed for some time and staff turnover was apparently very low prior to that. Staff files were not therefore looked at during this visit. The majority of care staff have gained an NVQ level 2 and all mandatory training has been completed as required. The deputy manager has attained an NVQlevel4. Cleaning staff have also gained appropriate qualifications. It was recommended that a training needs analysis should be complied to make it easier to identify the training that has been completed. Various other training sessions have been undertaken but, given the needs of the residents in this home, further training must be arranged for care staff with regard to dementia awareness. This would seem to have been limited so far to some input as a part of their NVQ training. .
Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who use this service do not benefit from being cared for by people who understand their specific needs. This lack of awareness questions the effectiveness of the Registered Providers in meeting the aims and objectives of the home. Arrangements for maintaining the health and safety of residents and for trying to gain their views of the service are in place although could be improved upon. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home is currently without a Registered Manager. This is an essential role to provide continuity of care and leadership within the home and this situation must be rectified as soon as possible. It is acknowledged that efforts are currently in place to address this shortfall. Since the last inspection a satisfaction survey was undertaken regarding the care and services provided by the home. It is intended that this should be repeated annually. There are currently no other opportunity’s to gain the views of residents or their representatives (including visitors to the home, such as Care Managers, Health Care Workers and General Practitioners) Other methods must be considered and the results of these surveys must be published and made available to current and prospective residents (where there is no response, published results should include information about how many people were surveyed and did not respond) Some money is held on behalf of residents. Records are maintained but all of the money is kept together. In future money must be kept in a way, which makes it possible to check that records are accurate. Some records that show the health and safety of residents and staff is ensured were seen and were generally in order. It was noted that water needs to be tested for bacterial analysis and portable appliances need to be tested for this year. Health and Safety practices in the kitchen area have improved and requirements made by the Environmental Health Officer have been met. It was recommended that a visit should be requested from the Fire Safety Officer and a Fire Risk Assessment must be undertaken in line with regulatory guidance. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X 1 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 1 X X 2 Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The Statement of Purpose must be updated to reflect the current situation in the home and explain how the needs of those who live there will be met. The Service User Guide must be updated, written in a format that is suitable for the people who will read it and made available to every resident; so that it provides a guide to the home and the services that will be provided. The pre-admission assessment must include evidence that consideration has been given to the social preferences of residents so that they can be sure that living in the home will suit them. People who use this service must have care plans, which include information about how intended outcomes will be achieved so that all the staff are aware of how they should be supported. All care plans must be written in ink or ballpoint pen so that that cannot be altered.
DS0000013381.V339607.R01.S.doc Timescale for action 30/08/07 2 OP1 5 30/08/07 3 OP3 14(1)(a) 30/08/07 4 OP7 15(1) 30/08/07 5 OP7 17(1)(b) 10/05/07 Cloyda Version 5.2 Page 24 6 OP7 15(1)(c) 7 OP12 16(2)(n) 8 9 OP12 OP15 16(3) 16(2)(i) 10 OP16 Schedule 4 (11) 23(2)(a) 11 OP19 12 OP19 23(2)(n) 13 OP19 23(2)(a) 14 OP19 13(4)(a) 15 16 OP19 OP19 16(2)(j) 13(4)(c) 17 OP23 16(2)(d) There must be evidence that residents or their representatives have been able to contribute to their care plans so that they can influence the way that care is given Residents must be offered a range of activities, which suit their capabilities and provide stimulation and interest. Residents must be given the opportunity to have their spiritual needs met. There must be evidence that residents have been asked about their likes and dislikes with regard to the food that they eat. There must be system available for people to register a concern or complaint with a record of any action taken and the outcomes. The home must provide a suitable environment, which meets the needs of the people who live there. People who use this service must be able to reach their call bells so that they can summon assistance as necessary. All of the fire doors leading out of the home must be alarmed so that staff are alerted if residents open them Locks must be put onto the shed and vacuum cleaner cupboard to prevent any injury or untoward incident occurring to residents. The kitchen tiles that are broken must be replaced so that a safe hygienic surface is maintained The door leading from the corridor into the laundry must be locked when not in use to protect residents from accidents. People who use this service must be encouraged to personalise their bedrooms so that they are
DS0000013381.V339607.R01.S.doc 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 30/08/07 Cloyda Version 5.2 Page 25 18 19 20 OP23 OP23 OP30 16(2)(c) 23(2)(c) 18(1)(c) 21 OP31 8 (1) (a) more homely. Stained beds and headboards in the home must all be replaced. Decoration in bedrooms intended for those who have dementia must suitable for their needs. Staff must attend training in dementia awareness to enable them to understand the needs of the people who live in this home. The Registered Provider must ensure that an application is made to the Commission for Social Care Inspection for the post of Registered Manager. Previous Timescale 15/04/07 not achieved. There must be evidence that those who live in or visit the home are given the opportunity to comment and influence the services provided. Money held on behalf of people living in the home must be kept in such a way, as it is possible to check that records are accurate. There must be evidence that all equipment and services in the home are properly maintained and checked. A fire risk assessment must be produced to show that all hazards have been identified and wherever possible minimised. 30/08/07 30/08/07 30/08/07 30/08/07 22 OP33 24(3) 30/08/07 23 OP35 16(2)(l) 30/08/07 24 OP38 23(2)(c) 30/08/07 25 OP38 23(4)(c) 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 26 1 2 3 4 5 6 7 OP3 OP15 OP18 OP19 OP19 OP23 OP30 It is recommended that a brochure or information pack should be produced, to show people who cannot visit prior to admission, what the home is like. It is recommended that picture menus should be introduced to help people decide on the meals that they would like to eat. It is recommended that all staff should receive additional training around adult abuse awareness so that they are aware of the processes to be followed It is recommended that colour co-ordination be used to highlight various facilities in the home such as toilets and bathrooms to help residents find their way around. It is recommended that advice should be taken from the Fire Safety Officer regarding suitable door locks on the fire doors to help maintain the safety of residents and staff. It is recommended that residents should be encouraged to bring in personal possessions to make their rooms more homely. It is recommended that a training needs analysis should be complied so that it is easier to identify which members of staff have attended training sessions. Cloyda DS0000013381.V339607.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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